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Question 1. Which of the following is the most characteristic light-microscopic finding in Minimal Change Disease (MCD) on renal biopsy? A) Mesangial hypercellularity B) Diffuse effacement of podocyte foot processes C) Subepithelial immune-complex deposits D) Thickened glomerular basement membrane Answer: B Explanation: Electron microscopy in MCD shows diffuse podocyte foot-process effacement, while light microscopy is often normal. Question 2. A 45-year-old man presents with nephrotic-range proteinuria, hypertension, and focal segmental sclerosis on biopsy. Which feature distinguishes primary FSGS from secondary FSGS? A) Presence of IgM deposits B) History of reduced renal mass C) Absence of a known cause and often response to steroids D) Segmental hyalinosis only Answer: C Explanation: Primary FSGS is idiopathic, often steroid-responsive, whereas secondary FSGS is linked to a known cause (obesity, reflux) and less steroid responsive. Question 3. Anti-phospholipase A2 receptor (PLA2R) antibodies are most strongly associated with which glomerular disease? A) IgA nephropathy B) Membranous nephropathy C) Lupus nephritis D) Diabetic nephropathy Answer: B Explanation: PLA2R antibodies are present in ~70% of primary membranous nephropathy and help differentiate it from secondary causes.
Question 4. In IgA nephropathy, the hallmark immunofluorescence pattern is: A) Linear IgG along the GBM B) Granular IgA dominant mesangial staining C) C3 “starry sky” pattern D) IgM and C1q deposition in subendothelial space Answer: B Explanation: IgA nephropathy shows dominant or co-dominant mesangial IgA deposits with a granular appearance. Question 5. According to the ISN/RPS classification, Class IV lupus nephritis is best described as: A) Focal (<50% glomeruli) proliferative lesions B) Diffuse (>50% glomeruli) proliferative lesions C) Isolated membranous lesions D) Minimal mesangial involvement only Answer: B Explanation: Class IV lupus nephritis involves diffuse proliferative changes affecting >50% of glomeruli. Question 6. Which of the following best explains the pathogenesis of diabetic nephropathy’s characteristic nodular glomerulosclerosis (Kimmelstiel-Wilson lesions)? A) Immune complex deposition B) Advanced glycation end-product (AGE) accumulation and mesangial matrix expansion C) Anti-GBM antibodies D) Complement activation via the alternative pathway Answer: B Explanation: Hyperglycemia leads to AGE formation, stimulating mesangial matrix production and nodular sclerosis.
Question 10. In thrombotic thrombocytopenic purpura (TTP), the deficiency of which enzyme is central to disease pathogenesis? A) ADAMTS B) Factor VIII C) Protein C D) Plasminogen Answer: A Explanation: Autoantibody-mediated severe deficiency of ADAMTS13 leads to large von Willebrand factor multimers and microthrombi. Question 11. Typical (Shiga-toxin) hemolytic-uremic syndrome (HUS) is most commonly associated with which exposure? A) Untreated hypertension B) Antibiotic-treated urinary tract infection C) Undercooked beef contaminated with E. coli O157:H D) Recent vaccination Answer: C Explanation: Shiga toxin–producing E. coli from contaminated food triggers endothelial injury causing HUS. Question 12. Complement-mediated atypical HUS frequently involves gain-of-function mutations in which complement component? A) C B) Factor B C) Factor H D) C5a Answer: C Explanation: Mutations in complement regulators, especially factor H, lead to uncontrolled alternative pathway activation. Question 13. Which equation is recommended by KDIGO for estimating GFR in adults without race adjustment?
A) Cockcroft-Gault B) MDRD C) CKD-EPI D) Schwartz formula Answer: C Explanation: The CKD-EPI equation provides the most accurate GFR estimate across a wide range of kidney function and does not require race coefficient. Question 14. A 58-year-old woman with CKD stage 3 has an albumin-to-creatinine ratio of 350 mg/g. According to KDIGO, what albuminuria category does she belong to? A) A1 (normal-to-mild) B) A2 (moderately increased) C) A3 (severely increased) D) Not classified Answer: C Explanation: ACR ≥300 mg/g defines the A3 (severely increased) albuminuria category. Question 15. Which of the following agents has been shown to reduce CKD progression independent of blood-pressure lowering? A) Thiazide diuretics B) Loop diuretics C) SGLT2 inhibitors D) Calcium channel blockers Answer: C Explanation: SGLT2 inhibitors (e.g., dapagliflozin) reduce albuminuria and slow GFR decline beyond their antihypertensive effect. Question 16. In CKD-MBD, secondary hyperparathyroidism is primarily driven by which of the following? A) Elevated calcium levels
C) HIF-prolyl hydroxylase inhibitors (e.g., roxadustat) D) Vitamin B12 supplementation Answer: C Explanation: HIF-PH inhibitors increase endogenous erythropoietin production and improve iron metabolism. Question 20. Uremic pericarditis most commonly presents with which ECG finding? A) Diffuse ST-segment elevation with PR depression B) Tall, peaked T waves C) Low voltage QRS complexes D) Right-bundle-branch block Answer: A Explanation: Uremic pericarditis causes a fibrinous pericardial inflammation leading to diffuse ST elevation and PR depression, similar to other pericarditis. Question 21. In CKD patients, accelerated atherosclerosis is largely attributed to which metabolic disturbance? A) Hyperuricemia B) Hyperphosphatemia-induced vascular calcification C) Low LDL cholesterol D) Elevated albumin levels Answer: B Explanation: Phosphate overload promotes medial vascular calcification, a key driver of premature atherosclerosis in CKD. Question 22. For a CKD patient with systolic blood pressure 140 mmHg, which of the following is the KDIGO target blood pressure? A) < 130/80 mmHg only if proteinuria > 1 g/day B) < 150/90 mmHg for all CKD stages C) < 140/90 mmHg regardless of proteinuria D) < 120/80 mmHg for all patients
Answer: A Explanation: KDIGO recommends < 130/80 mmHg when albuminuria ≥30 mg/g; otherwise < 140/90 mmHg is acceptable. Question 23. Which lifestyle modification has the greatest impact on lowering blood pressure in essential hypertension? A) Sodium restriction to < 2 g/day B) Daily consumption of 2 L of orange juice C) Increasing protein intake to 2 g/kg D) Using a standing desk Answer: A Explanation: Reducing dietary sodium markedly decreases volume-dependent hypertension. Question 24. Primary aldosteronism is best screened with which ratio? A) Aldosterone-to-renin ratio (ARR) > 30 ng/dL per ng/mL/h B) Plasma renin activity > 5 ng/mL/h C) Serum cortisol > 20 μg/dL D) Urinary catecholamines > 500 μg/24 h Answer: A Explanation: An elevated ARR (aldosterone/renin) is the most sensitive screening test for primary aldosteronism. Question 25. Fibromuscular dysplasia (FMD) typically affects which renal artery segment? A. Ostial atherosclerotic plaque B. Mid-to-distal renal artery with a “string-of-beads” appearance C. Entire aorta D. Renal vein Answer: B Explanation: FMD causes alternating stenosis and aneurysmal dilatation of the mid-to-distal renal artery, visible as string-of-beads on imaging.
A) Inhibiting cyst-growth via vasopressin V2-receptor antagonism B) Blocking mTOR pathway C) Enhancing sodium reabsorption in the loop of Henle D) Stimulating aquaporin-2 expression Answer: A Explanation: Tolvaptan antagonizes V2 receptors, reducing cAMP-mediated cyst proliferation and fluid secretion. Question 30. A child with autosomal recessive polycystic kidney disease (ARPKD) typically presents with: A) Isolated hypertension in adulthood B) Hepatic fibrosis and congenital hepatic fibrosis C) Nephrolithiasis in early childhood D) Hyperuricemia only Answer: B Explanation: ARPKD often includes congenital hepatic fibrosis and portal hypertension. Question 31. Acute interstitial nephritis (AIN) most commonly presents with which triad? A) Fever, rash, eosinophilia B) Polyuria, polydipsia, weight loss C) Hematuria, flank pain, pyuria D) Hyperkalemia, metabolic acidosis, edema Answer: A Explanation: Drug-induced AIN frequently presents with fever, rash, and eosinophils in blood or urine. Question 32. Which medication is most frequently implicated in drug-induced AIN? A) Metformin B) Proton pump inhibitors (PPIs)
C) Statins D) Beta-blockers Answer: B Explanation: PPIs are a leading cause of AIN, often with a delayed onset after months of therapy. Question 33. Distal (type 1) renal tubular acidosis is associated with which of the following laboratory findings? A) Low urine pH (< 5.5) despite systemic acidosis B) High urine pH (> 5.5) despite systemic acidosis C) Normal anion gap metabolic alkalosis D) Hyperchloremic metabolic alkalosis Answer: B Explanation: Impaired H⁺ secretion leads to an inappropriately high urine pH in the setting of systemic acidosis. Question 34. A patient with proximal RTA (type 2) will most likely have which additional abnormality? A) Hypercalciuria leading to nephrolithiasis B) Hyperkalemia C) Metabolic alkalosis D) Low urine osmolarity Answer: A Explanation: Proximal bicarbonate loss causes calcium phosphate stone formation due to chronic hypercalciuria. Question 35. Type 4 RTA is most commonly seen in patients receiving which medication? A) Loop diuretics B) ACE inhibitors or ARBs C) Thiazides D) Carbonic anhydrase inhibitors
Question 39. In hepatorenal syndrome (HRS) type 1, the most effective pharmacologic therapy includes: A) High-dose furosemide B) Albumin infusion combined with a vasoconstrictor (terlipressin) C) Intravenous dopamine D) ACE inhibitor initiation Answer: B Explanation: Albumin expands intravascular volume, and terlipressin (or norepinephrine) improves renal perfusion by splanchnic vasoconstriction. Question 40. To prevent contrast-induced AKI (CI-AKI) in a patient with eGFR = 45 mL/min/1.73 m², the best strategy is: A) High-dose IV normal saline pre- and post-contrast (1 mL/kg/h for 12 h) B) Administration of N-acetylcysteine oral 600 mg BID for 2 days C) Using iso-osmolar contrast media only D) No prophylaxis needed because eGFR > 30 Answer: A Explanation: Isotonic saline hydration is the most evidence-based method to reduce CI-A KI risk; N-acetylcysteine has inconsistent benefit. Question 41. A donor with a PRA of 80% is considered: A) Low-risk for hyperacute rejection B) High immunologic risk, requiring desensitization before transplantation C) Ideal candidate for living donor transplantation D) Unacceptable for any transplant program Answer: B Explanation: High PRA indicates pre-formed antibodies; desensitization (plasmapheresis, IVIG) is often needed. Question 42. Thymoglobulin (anti-thymocyte globulin) is used primarily for:
A) Maintenance immunosuppression B) Induction therapy in high-risk kidney transplant recipients C) Treatment of BK virus nephropathy D) Prophylaxis against CMV Answer: B Explanation: Thymoglobulin provides potent T-cell depletion for induction in high-risk patients. Question 43. Which of the following is characteristic of antibody-mediated rejection (AMR) on allograft biopsy? A) Interstitial inflammation with tubulitis only B. Presence of C4d deposition in peritubular capillaries C. Granulomatous inflammation D. Diffuse podocyte effacement Answer: B Explanation: C4d staining indicates complement activation by donor-specific antibodies, hallmark of AMR. Question 44. The most common viral infection causing BK virus nephropathy occurs at which time post-transplant? A) Within the first week B) 1- 3 months C) 6- 12 months D) > 5 years Answer: C Explanation: BK reactivation typically peaks 6- 12 months after transplantation when immunosuppression is maximal. Question 45. For prophylaxis against Pneumocystis jirovecii pneumonia (PJP) in kidney transplant recipients, the preferred regimen is: A) Trimethoprim-sulfamethoxazole (TMP-SMX) for 6- 12 months
D) 12 L
Answer: C Explanation: Free water deficit ≈ 0.6 × body weight × [(Na/140) − 1] = 0.6 × 70 × (160/140 − 1) ≈ 8 L. Question 49. In nephrotic syndrome, the primary mechanism of edema formation is:** A) Sodium retention due to hypoalbuminemia-induced oncotic pressure loss B) Direct glomerular leakage of water C) Increased capillary hydrostatic pressure from heart failure D) Lymphatic obstruction Answer: A Explanation: Low plasma oncotic pressure from hypoalbuminemia leads to fluid shift into interstitium; secondary renal sodium retention worsens edema. Question 50. Which of the following is the most common cause of hyperkalemia in CKD patients? A) Excess dietary potassium B) Reduced distal tubular secretion due to decreased aldosterone activity C) Increased renal tubular reabsorption of potassium D) Metabolic alkalosis Answer: B Explanation: Impaired aldosterone-mediated secretion in the distal nephron is the principal driver of hyperkalemia in CKD. Question 51. The classic ECG change of severe hyperkalemia (> 7 mmol/L) is:** A) Tall, peaked T waves B) Prolonged QT interval C) ST-segment depression D) U waves Answer: A
Explanation: Hyperkalemia causes rapid repolarization manifesting as peaked T waves. Question 52. In the evaluation of hypokalemia, a transtubular potassium gradient (TTKG) > 7 suggests:** A) Renal potassium loss (e.g., diuretics, hyperaldosteronism) B) Extrarenal loss (e.g., GI) C) Normal renal handling D) Pseudohypokalemia Answer: A Explanation: High TTKG indicates that kidneys continue to excrete potassium despite systemic deficiency, pointing to renal loss. Question 53. The most common stone composition in patients with hyperparathyroidism is:** A) Calcium oxalate B) Struvite C) Uric acid D) Cystine Answer: A Explanation: Elevated calcium excretion predisposes to calcium oxalate stone formation. Question 54. A 30-year-old woman with recurrent calcium oxalate stones is found to have low urinary citrate. Which dietary recommendation is most appropriate? A) Increase animal protein intake B) Decrease dietary potassium C) Increase intake of citrus fruits (e.g., lemonade) D) Restrict fluid intake to 1 L/day Answer: C Explanation: Citrate inhibits stone formation; citrus fruits increase urinary citrate.
Question 58. A patient on long-term PPIs develops hypomagnesemia. The mechanism is:** A) Increased renal excretion due to tubular dysfunction B) Decreased intestinal absorption secondary to reduced gastric acidity C) Direct chelation of magnesium in the bloodstream D) Enhanced urinary magnesium reabsorption Answer: B Explanation: PPIs reduce gastric acid, impairing magnesium absorption in the intestine. Question 59. In a patient with CKD stage 4, the recommended protein intake according to KDOQI is:** A) 0.8 g/kg/day (standard) B) 1.2 g/kg/day (high) C) 0.6 g/kg/day (low) D) No restriction needed Answer: C Explanation: KDOQI suggests 0.6 g/kg/day for non-dialysis CKD to reduce nitrogenous waste production. Question 60. Which antibiotic requires dose adjustment in patients with a CrCl < 30 mL/min due to renal clearance? A) Azithromycin B) Ciprofloxacin C) Metronidazole D) Doxycycline Answer: B Explanation: Ciprofloxacin is primarily renally excreted and needs dose reduction in impaired renal function. Question 61. The primary nephrotoxic mechanism of aminoglycosides is:** A) Inhibition of prostaglandin synthesis
B) Accumulation in proximal tubular cells causing oxidative injury and necrosis C) Direct glomerular basement membrane disruption D) Blocking carbonic anhydrase Answer: B Explanation: Aminoglycosides concentrate in proximal tubular lysosomes, leading to phospholipidosis and cell death. Question 62. Which anticoagulant is safest to use in a patient with a CrCl of 15 mL/min? A) Apixaban (standard dose) B) Dabigatran (full dose) C) Warfarin (dose-adjusted INR) D) Rivaroxaban (full dose) Answer: C Explanation: Warfarin is metabolized hepatically and does not require renal dose adjustment; direct oral anticoagulants need dose reduction or avoidance. Question 63. A 65-year-old with CKD stage 5 on hemodialysis presents with pruritus and a serum phosphorus of 7.2 mg/dL. First-line therapy to lower phosphate is:** A) Calcium acetate B) Sevelamer carbonate C) High-dose vitamin D analogs D) Sodium bicarbonate Answer: B Explanation: Non-calcium binders like sevelamer are preferred in dialysis patients to avoid calcium overload. Question 64. In a patient with CKD and anemia, a TSAT of 15% and ferritin of 300 ng/mL most likely reflects:** A) Iron deficiency anemia B) Functional iron deficiency (iron-restricted erythropoiesis)
